Nutritional, inflammatory and functional biomarkers in lung cancer : identifying patients at risk of adverse outcomes through two retrospective cohort studies

Background Lung cancer is the commonest cause of cancer death worldwide. A range of biomarkers are associated with adverse outcomes in lung cancer, but these have not been assimilated into routine clinical practice. The aim of the two studies was to identify predictive variables within existing healthcare data for adverse outcomes following lung cancer treatment, with a view to informing optimal treatment selection for future patients. Methods Two retrospective cohort studies of lung cancer patients in South East Scotland were undertaken using demographic and clinical data from healthcare records. A range of explanatory variables were explored using descriptive statistics, logistic regression and survival analysis for treatment-related outcomes. These included overall survival (OS), early mortality and treatment completion. Results 194 patients were included the chemoradiotherapy study, median OS 19 months. Low skeletal muscle attenuation (MA), (odds ratio [OR] 1.61 [95% CI 1.16, 2.23, p=0.004) independently predicted reduced OS. Independent predictors of death within 90 days of treatment completion were Eastern Cooperative Oncology Group Performance Status ≥2 (OR 3.97 [1.20, 13.08], p=0.024) and body mass index (BMI) ≤20 (OR 3.91 [1.24, 12.38], p=0.020). 397 patients were included in the palliative chemotherapy study, median OS 6.9 months. Independent predictors of reduced OS were: neutrophil-to-lymphocyte ratio ≥4, albumin <35, MA and low skeletal muscle mass. Patients who did not receive guideline-recommended treatment (GRT) had a median OS of 3.3 months. Independent predictors of non-GRT receipt were: non-small cell lung cancer, BMI ≤20, neutrophil count ≥7, lymphocyte count <1 and MA <31.55. Discussion A range of routinely available biomarkers can identify patients with lung cancer at increased risk of adverse outcomes. Optimal treatment selection for each patient could be improved by routine utilising these biomarkers. Biomarkers may also be useful to identify patients for integrated supportive care during their cancer treatment. Further research is needed

Intensity of care in cancer patients in the last year of life: a retrospective data linkage study

BACKGROUND: Delivering high-quality palliative and end-of-life care for cancer patients poses major challenges for health services. We examine the intensity of cancer care in England in the last year of life. METHODS: We included cancer decedents aged 65+ who died between January 1, 2010 and December 31, 2017. We analysed healthcare utilisation and costs in the last 12 months of life including hospital-based activities and primary care. RESULTS: Healthcare utilisation and costs increased sharply in the last month of life. Hospital costs were the largest cost elements and decreased with age (0.78, 95% CI: 0.73–0.72, p < 0.005 for age group 90+ compared to age 65–69 and increased substantially with comorbidity burden (2.2, 95% CI: 2.09–2.26, p < 0.005 for those with 7+ comorbidities compared to those with 1–3 comorbidities). The costs were highest for haematological cancers (1.45, 95% CI: 1.38–1.52, p < 0.005) and those living in the London region (1.10, 95% CI: 1.02–1.19, p < 0.005). CONCLUSIONS: Healthcare in the last year of life for advanced cancer patients is costly and offers unclear value to patients and the healthcare system. Further research is needed to understand distinct cancer populations’ pathways and experiences before recommendations can be made about the most appropriate models of care

Definitions of advanced multimorbidity : a scoping review

Funding: Wellcome Trust (223499/Z/21/Z) (SB).Background Increasing numbers of people are living with and dying from multimorbidity (the presence of two or more physical or mental health conditions). However, it has been seen as challenging to identify when people with multiple health conditions may be approaching the end of life (so-called advanced multimorbidity). Aims & Objectives This scoping review aims to comprehensively detail how advanced multimorbidity are currently defined in research, policy and clinical practice. Methods This scoping review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search strategy was developed and implemented into Medline, EMBASE, CINAHL, Scopus and PsychINFO. A further grey literature search was undertaken. Title and abstract then full text screening was undertaken by three co-reviewers. The study’s Public Advisory Group have been instrumental in shaping the research question and summarising our findings. Results From 13,758 initial studies 9499 titles and abstracts screened 760 full texts screened approximately 50 full texts included. There were no studies found from low-middle income countries. Various study designs were utilised, most were retrospective observational studies. Definitions of advanced multimorbidity were often study-specific however a few used a validated prognostic tool e.g. NECPAL. Very few end-of-life care policies were specific to people with advanced multimorbidity. Conclusion The results of this scoping review will enable researchers, policy makers, clinicians and patients to better understand ways to identify when people with multimorbidity may be approaching the end of life.Publisher PDFPeer reviewe

Current definitions of advanced multimorbidity: a protocol for a scoping review

INTRODUCTION: People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice.METHODS AND ANALYSIS: Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions.ETHICS AND DISSEMINATION: Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.</p

Patient perceptions of their decision to undergo palliative chemotherapy in the Edinburgh Cancer Centre

Background The decision to undergo chemotherapy for incurable cancer demands informed discussions about the risks and benefits of proposed treatments. Research has shown that many patients have a poor grasp of these factors. Methods An evaluation of the patient experience of palliative chemotherapy decision-making was undertaken. Patients with lung or gynaecological cancers were surveyed about their decision, what they understood about its risks and benefits, and how supported they felt. Results A total of 29 people with lung cancer (n = 21) or gynaecological cancer (n = 8) completed questionnaires. The majority felt sure about their decision, though many were less sure of the risks and benefits of treatment. Unprompted comments revealed significant nuance, including that the decision to undergo chemotherapy may not necessarily have felt like a choice. Conclusions Our positive findings may reflect participant selection bias, or could represent genuine comfort in decision-making in Scottish oncology clinics. Further research is needed.Publisher PDFPeer reviewe

Variation in hospital cost trajectories at the end of life by age, multimorbidity and cancer type

Background Approximately thirty thousand people in Scotland are diagnosed with cancer annually, of whom a third live less than one year. The timing, nature and value of hospital-based healthcare for patients with advanced cancer are not well understood. The study's aim was to describe the timing and nature of hospital-based healthcare use and associated costs in the last year of life for patients with a cancer diagnosis. Methods We undertook a Scottish population-wide administrative data linkage study of hospital-based healthcare use for individuals with a cancer diagnosis, who died aged 60 and over between 2012 and 2017. Hospital admissions and length of stay (LOS), as well as the number and nature of outpatient and day case appointments were analysed. Generalised linear models were used to adjust costs for age, gender, socioeconomic deprivation status, rural-urban (RU) status and comorbidity. Results The study included 85,732 decedents with a cancer diagnosis. For 64,553 (75.3%) of them, cancer was the primary cause of death. Mean age at death was 80.01 (SD 8.15) years. The mean number of inpatient stays in the last year of life was 5.88 (SD 5.68), with a mean LOS of 7 days. Admission rates rose sharply in the last month of life. One year adjusted and unadjusted costs decreased with increasing age. A higher comorbidity burden was associated with higher costs. Major cost differences were present between cancer types. Conclusions People in Scotland in their last year of life with cancer are high users of secondary care. Hospitalisation accounts for a high proportion of costs, particularly in the last month of life. Further research is needed to examine triggers for hospitalisations and to identify influenceable reasons for unwarranted variation in hospital use among different cancer cohorts

Getting into hot water:sick guppies frequent warmer thermal conditions

Ectotherms depend on the environmental temperature for thermoregulation and exploit thermal regimes that optimise physiological functioning. They may also frequent warmer conditions to up-regulate their immune response against parasite infection and/or impede parasite development. This adaptive response, known as ‘behavioural fever’, has been documented in various taxa including insects, reptiles and fish, but only in response to endoparasite infections. Here, a choice chamber experiment was used to investigate the thermal preferences of a tropical freshwater fish, the Trinidadian guppy (Poecilia reticulata), when infected with a common helminth ectoparasite Gyrodactylus turnbulli, in female-only and mixed-sex shoals. The temperature tolerance of G. turnbulli was also investigated by monitoring parasite population trajectories on guppies maintained at a continuous 18, 24 or 32 °C. Regardless of shoal composition, infected fish frequented the 32 °C choice chamber more often than when uninfected, significantly increasing their mean temperature preference. Parasites maintained continuously at 32 °C decreased to extinction within 3 days, whereas mean parasite abundance increased on hosts incubated at 18 and 24 °C. We show for the first time that gyrodactylid-infected fish have a preference for warmer waters and speculate that sick fish exploit the upper thermal tolerances of their parasites to self medicate

Context-dependent community facilitation in seagrass meadows along a hydrodynamic stress gradient

Foundation species host diverse associated communities by ameliorating environmental stress. The strength of this facilitative effect can be highly dependent on the underlying biotic and abiotic context. We investigated community level patterns of macrofauna associated with and adjacent to the marine foundation species eelgrass (Zostera marina) along a hydrodynamic stress gradient. We could demonstrate that the relative importance of this foundation species for its infaunal community increases with environmental variables associated with increasing hydrodynamic stress (depth, sand ripples formation, sediment grain size and organic content). Faunal assemblages in proximity to the Zostera patch edges, however, showed no (infauna) or negative (epifauna) response to hydrodynamic stress. Our study highlights that the facilitative outcome of a foundation species is conditional to the faunal assemblage in question and can be highly variable even between positions within the habitat.Peer reviewe